My new book, "Health, Medicine and Justice: Designing a fair and equitable healthcare system", is out and and widely available!
Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Saturday, October 31, 2009

.Lots of people take non-prescription “food supplements”, nutritional additives, “vitamins”, “energy tonics”, etc. These are particularly attractive if they are labeled “natural” or “organic”. For some folks, the goal is “general health” – the vitamins, minerals, herbs and other preparations, the herbs that. Many of the users of these substances, whether bought from retail outlets or over the internet are precisely those who disdain prescription medications, who don’t like to “take drugs” but take these “natural” substances. Others are taking them for a specific purpose – weight loss, muscle building, pain relief, energy – often when their doctors have refused to prescribe them, because they are dangerous, or illegal, or both.

Thus, we might conceive of two groups of the 114 million of us who take these medications. “Group 1” are those who believe in “natural” and are trying to “naturally” get healthier. “Group 2” wants magic drugs to help them achieve a goal, would be happy to take them if they could find a doctor to prescribe them, but can’t. Unfortunately, this is much a more hypothetical than real distinction, as there is considerable overlap. Many people in the first group can find their way into the other when they develop symptoms. Especially if the treatments are ostensibly “natural”.

A “Perspective” article in the New England Journal of Medicine, October 15, 2009, by Pieter A. Cohen, MD, titled “American Roulette – Contaminated Dietary Supplements”, discusses these issues. Cohen starts by discussing a police sergeant who lost his job after random drug tests found him positive for amphetamines – an unlabeled ingredient present in the weight-loss supplement he had been taking. It goes on to discuss contaminants found in many such over the counter supplements, both imported and made in USA, sold in retail stores and over the Internet. He notes that the 140 contaminated supplements that the FDA has identified are only a small percentage of those on the market; recently 75 weight-loss drugs were found to be contaminated. And “contamination” is not always the correct word. It implies inadvertent (although perhaps through inadequate quality control) substances present that are not on the label – such as rodent hairs or lead or other heavy metals (beryllium, cadmium, arsenic, etc., which are all poisons that accumulate in the body), bacteria, and plant molds. However, frequently the “off-label” ingredients are there on purpose – they are the drugs that are actually having the desired effect – amphetamines for weight loss or energy, anabolic steroids for muscle building, corticosteroids for arthritis relief, opiates for pain. And these are drugs that are illegal to sell without a prescription (and often heavily restricted even with a prescription!) so they are left off the label. And, in part because the FDA has had its budget gutted and has too few inspectors, are undetected.

There are other reasons that the FDA does not detect such accidental or purposeful adulteration. One is the Dietary Supplement Health and Education Act (DSHEA) of 1994, that limited the ability of the FDA to regulate them. The DSHEA was pushed by the supplement manufacturers, with support of many ordinary people who feared that increased FDA regulation would lead to loss of free access to these substances. Before 1994, Cohen writes, “These supplements, which include botanical products, vitamins and minerals, amino acids, and tissue extracts…were considered food additives, and their manufacturers were required to show proof of safety before marketing them. Since the passage of the DSHEA, dietary supplements are presumed to be safe and can be marketed with very little oversight.” And American consumers, looking for magic potions, pay the price in their health.

There are a few things to remember when considering purchasing and taking dietary supplements, even ones you have long taken. They include:

--“Natural” does not mean “good” or even “safe”.There are plenty of natural poisons, and most substances, taken in excessive amounts can have adverse effects. Similarly, “made in a pharmaceutical laboratory” does not mean “bad”; usually, if it is a reputable and inspected lab (including the pharmaceutical manufacturers I often criticize) it means that there is much more quality control.

­--If a substance actually has “good” effects, it can also have “side effects”.Substances only have effects. They don’t know what you want and don’t want. If a substance is actually having biological effects on your body (as opposed to psychological placebo effects), it doesn’t matter if it is “natural” or manufactured, from a plant or a chemical. If, for example, the estrogens in plants “work” just as well as those from animals (mare urine) or chemically produced, they will have the same sort of risks.

--Unregulated or under-regulated substances are often “contaminated”, and this is particularly true for those made in other countries and often bought over the Internet. In this case I mean truly “contaminated”, with the lead, bacteria, molds, and toxins I mention above.

--Plants vary in potency. Thus “1 leaf” or “1 ounce” of a plant may have very different amounts of active ingredient depending upon where and what season it was grown in, and just in terms of random variation. If you buy the actual plants – and if you are a skilled enough botanist to be sure of what you are buying – the variable potency needs to be considered. If, however, you are buying capsules said to contain a specific plant, you are, as described above, shooting craps with your health, because these are subject to much less regulation than “standard” pharmaceuticals.

--If it seems too good to be true, it almost certainly is. If a substance you buy, over the Internet or from a retailer, works amazingly well, it is likely that it contains, probably unlabeled, a very potent drug such as steroids, amphetamines, or opiates. Maybe you knew that and wanted it because your mean doctor would not prescribe them. Maybe that makes you unwise. However, if you bought them under the impression that they were “natural” and “safe”, you may be in for a big surprise. And this is likely to be in terms of the serious adverse effects that led them to be highly regulated in the first place.

Finally, the people manufacturing and selling these “supplements” are profit-making companies. Calling themselves “organic” or “natural” does not make them automatically nice, safe, good guys. As in any other industry, as we have seen so often over the last year, there are opportunists who will lie, cheat, steal, and poison you to make a buck. Strong regulation, well-funded regulation, is the only thing we have on our side to protect us. Limiting regulations of substances that can affect our health is almost always wrong. The DSHEA was a mistake, and well-meaning people who supported it made a mistake in doing so. They now need to demand that their legislators protect them at least as much from over-the-counter dietary supplements as they do from prescription drugs!.

Tuesday, October 27, 2009

I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special Report: Cancer Treatment Options," paid for by some of our finest cancer centers. [1] In the prostate cancer section, I found this interesting assertion, in big capital letters: "The PSA test for prostate cancer detection and management is one of medicine's great success stories." It goes on to say that 90% of prostate ca is now diagnosed when curable and that the death rate has declined by 40% since the PSA test began to be widely used in the 1980's. The source is the chair of urology and senior vice president for translational research at Roswell Park Cancer Institute in Buffalo, where the the PSA test was developed.

I found the assertion curious because this past March the New England Journal of Medicine published 2 long-awaited studies[2],[3] on whether PSA testing was effective: one found a modest benefit and the other virtually none. Both noted that a very large number of men had to be screened and treated for every one who benefited. These articles received extensive press coverage. And just as I was going to my laptop today to assemble this and other maybe-not-such-a-great-success-story evidence for PSA screening, this week's JAMA showed up with a terrific paper by Esserman, Shieh, and Thompson.[4] They have this to say about PSA screening:"After 2 1/2 decades of screening for [breast and] prostate cancer, conclusions are troubling: Overall cancer rates are higher, many more patients are being treated, and the absolute incidence of aggressive or later-stage disease has not been significantly decreased. Screening has some effect, but it comes at significant cost, including over-diagnosis, overtreatment, and complications of therapy."

So how do we get from "great success story" to "troubling"? How can diagnosing cancer early not be a good thing? The answer lies in the kind of cancers we can detect with screening. Slow growing cancers, the kind unlikely to kill you, grow... slowly and so are around for a long time to be detected by screening. On the other hand, fast growing cancers can go from undetectable to lethal even in the year between cancer screenings. So the cancers we detect through screening are more likely to be the non-lethal kind. Well, isn't that still a good thing? Can't cancer harm without killing?

Yes, but the issue here is what we call "cancer." Our screening tests can detect collections of cells that are, by pathologists' standards, "cancer" when viewed under the microscope, yet not every collection of such cells is destined act like cancer; that is, to grow or spread (metastasize) to other parts of the body. Some are destined to remain dormant until the person eventually dies of something else. And therein lies the problem with PSA screening. It detects many of the ones destined to be dormant or slow growing for every one destined to be lethal. The exact number is uncertain, but the large European study in the NEJM this March estimated 1410 men needed to be screened and 48 cases of prostate cancer treated to prevent 1 death. [2] The American study released in parallel found the benefits to be even smaller. [3]

What this means, is that the consequence of PSA testing for many men is adding 6-12 years of life diagnosed -- and often treated -- as a cancer patient, without actually living any longer.

Just how much over-diagnosis can we attribute to PSA? In the August 2009 issue of the Journal of the National Cancer Institute, H. Gilbert Welch and Peter Alberson calculate than in the first 19 years of the PSA era, 1987 to 2005, about 1.3 million additional cases were diagnosed and 1 million more men treated.[5] They estimate that about half of these extra cases represent over-diagnosis, meaning that the diagnosed man was very unlikely to die from prostate cancer. So of the roughly 4 million men diagnosed from 1985 to 2005, half a million were over-diagnosed.

What about the fact that, as the Roswell Park urologists note, mortality rates have fallen since PSA testing began in the mid-80's? Doesn't that suggest that PSA is helping? The authors in this week's JAMA paper address this in their analysis. For that claim to be credible, we should be seeing a sharp fall in number of advanced stage prostate cancers, which is what would happen if screening was finding the "bad" cancers early, before they could reach an advanced stage. Although we have indeed seen a fall in advanced cancers it has been nowhere near as sharp as we would expect, given the many more cancers we are finding in the PSA era. We should thus probably look elsewhere to explain the fall in prostate cancer mortality, likely improvements in treatment.

So, given what we know about how well PSA testing performs as a screening test, how can it be advertised as one of medicine's great success stories? As potential explanations, I offer two themes that I believe also offer some larger lessons for why health care is less effective and more expensive than it should be.

Theme 1: Thinking about organs rather than people: If your focus is the prostate, then finding and removing cancerous prostates is the goal. This works well at the level of prostates, but not so well for whole men. With a test as imperfect as the PSA, a small or nonexistent reduction in the risk of dying from prostate cancer is sometimes traded for diminished quality of life, most commonly the incontinence and impotence that affect about 1/4 of men treated for prostate cancer.

Theme 2: Economic incentives favoring procedures. As the numbers above demonstrate, PSA has expanded the number of prostate cancer patients by about a third. The professional urology association has long recommended PSA screening even when the US Preventive Services Task Force, tasked with providing rigorous assessments for screening procedures, has consistently recommended against routine PSA screening.

Themes 1 and 2 intertwine. Greed is not what drives PSA testing. When a urologist can make a prostate cancer diagnosis and provide a "cure," doctor and patient alike perceive it as a valuable service. A life-saving intervention. That the service is well reimbursed appears justified when the stakes seem so high. It is only from the application of healthy skepticism and careful analysis -- of outcomes for people, not organs -- that we can reach better conclusions about the value of what we do.

Friday, October 23, 2009

.The humorist Calvin Trillin had a recent column in the NY Times advancing his theory as to what changed on Wall St. that led to the orgy of greed that both came close to destroying our economy and continues to this day. Because he is a humorist, “Wall Street Smarts” is funny, but its premise is probably, sadly, true. He argues that in his day the smart kids became relatively-low paid professors, judges, etc., while the kids who went on to enter Wall St. careers were from the lower end of his college class, often from families that had long histories of such work and such money (perhaps that is why they didn’t feel they had to work so hard in school). They expected to be rich, but more in the “big house in Greenwich and a sailboat” than the “second oceangoing yacht” rich. But when the “smart kids” entered Wall St. they no longer worked “bankers’ hours” nor were satisfied with the “products” that financiers had long purveyed. They lobbied successfully for changes in laws and regulations and developed new products such as derivatives that nobody understood[1] and made, well, oodles.

And now they are still doing it. We stood at the precipice of global financial collapse and were pulled back only by massive public investment into the finance and banking system. Even “progressives” argued that these institutions, like Goldman Sachs, were “too big to fail”. So we bailed them out and they are now back to making billions of dollars (like Goldman’s most recent quarterly profit) while too many Americans are out of work, and out of hope. The fault lies squarely at the feet of Congress, who is, as on healthcare, totally influenced by the contributions of the wealthy corporations that they continue to do their bidding, and on the administration of President Obama, which has appointed so many insiders that we can’t tell who is actually going to regulate them. The “revolving door” is certainly not new; it has characterized every recent administration, both Republican and Democratic, but we had hoped it would change with this new president.

It hasn’t. Treasury Secretary Timothy Geithner spends all his time on the phone with the executives of Goldman and CitiBank. Chief economic advisor Lawrence Summers comes from Goldman via Harvard. Goldman chief and former Clinton Treasury Secretary Robert Rubin is the current “guru” of financial advice to the President. We keep hoping that the President will, on this issue, on health care, on Afghanistan, take a bold leadership position, but we keep being disappointed. Sunday, Oct 18, 2009’s papers are full of depressing insights. In the NY Times, Maureen Dowd describes in depressing detail President Obama’s history of compromising so much that the baby is lost and the bath water leaks away (“Fie, fatal flaw!”). Frank Rich has a detailed column on the excesses of Goldman Sachs (“Goldman, can you spare a dime?”), comparing them unfavorably to JD Rockefeller’s Standard Oil and the administration’s attempts at regulation unfavorably to Teddy Roosevelt’s. Steve Breen, in his syndicated cartoon in the Kansas City Star, depicts Wall St. at a bar drinking from a bottle labeled “Risk” and saying “I keep drinking ‘cause I have a designated driver”, while a car with the license plate “Bailouts” and Uncle Sam at the wheel idles outside.

This has to stop. The administration needs to fire all the Summerses, Rubins, and Geithners, and get some hard-nosed prosecutors with no sympathy for these folks, like the legendary Ferdinand Pecora of the 1930s, in to reign in these folks. And Congress, with the urging of the administration, needs to pass laws that take these stolen profits away through both a windfall profits tax and limitations on executive income. How much should they be allowed to make? $50,000? $500,000? $2 million? Some amount, and take the rest.

And do what with it? I have said many times that we – represented by the government that is supposed to be ours – should take all that money so that these Wall St. financiers are reduced to living in surplus FEMA trailers. The President has taken some flak because he just made his first trip to New Orleans since taking office (although he traveled there several times since Katrina as a Senator and a candidate) for a visit that lasted only a few hours (and had to end so he could make a fund-raising event in San Francisco). Let’s use the money to rebuild New Orleans. Then this wealth would be used for a good purpose, channeling it back to the people from whom it was stolen.

We are told by Wall St. that limitations on the income of financiers would make it difficult or impossible for them to lure the “best and the brightest”. Maybe Calvin Trillin is right, and having the “best and the brightest” working on Wall St. is part of the etiology of the problem. Maybe they should go back to being professors, judges, doctors, scientists. Solving real problems that the world faces in the environment, human rights, and health. I can’t see any downside.

[1] That’s because they don’t really exist. They are a Ponzi scheme which, through repackaging, sells the same stuff over and over again. And, like a Ponzi scheme, customers who don’t understand it are happy as long as they are making money, but it always collapses. However our new Wall St. tyros learned one thing from traditional brokers – whether the customer is winning or losing, you always take your cut!

Tuesday, October 20, 2009

.The Business section of the New York Times on October 10, 2009, had a small article by Floyd Norris called “The Divided State of Health Care”. It looks at which states and, within those states, Congressional districts, have the highest number of uninsured. In a neat series of graphics, states are divided into “blue” (voted for Obama, have 2 Democratic senators), “red” (voted for McCain, have 2 Republican senators) and “purple” (some other combination). The red states had the highest percent of uninsured, led by my former state, Texas, with 26.5% of those under 65, including 17.8% of children under 18, uninsured. While not linear (the second highest percentage of uninsured is in Florida, a “purple” state, and third is New Mexico, a “blue” state), the association is strong. My home state of Kansas, which has only one (of 4) Democratic congressional districts, and only 2 of 105 counties that voted for the President, is the "best” of the red states. However, its 13.8% uninsured is worse than 14 of the 21 bluestates and 7 of the 17 purple states.

From an ideological point of view, this is not surprising, given the vicious opposition of the Republican Party to any type of meaningful health reform. From a practical point of view, it might be surprising – why are the leaders of those states, where there is such great need, not interested in addressing that need? Or, at least, why do the people in the states that have such great need keep re-electing folks who oppose meeting their need? Part of the explanation may come from the second half of the analysis, which shows that it is theblue (Democratic) congressional districts within the red states that have the highest number of uninsured people. This is because these districts have a lot of poor and minority people and vote Democratic, but to the majority of people in the rest of those states, are the “other”: “Of the 10 Congressional districts with the least health insurance,” writes Norris, “seven are in Texas, two in California and one in Florida. Nine of those districts are largely black or Hispanic, and are represented by Democrats who faced little if any Republican opposition in the last election.” Whether this is explained mostly by classism, racism, or something else is an interesting question, but the result is that if you are a poor or minority person in a conservative state, you are in particularly bad straits.

Of course, it is not only the poor minority inner-city people who are left out. In Kansas, while Wyandotte County (Kansas City), one of the “blue” counties, is the poorest county, and also has a high percent of minorities, the next 6 poorest are in rural, white southeast Kansas. Why do these folks vote against their self-interest for Republicans? (Well, they don’t always.[1]) Some of it is that there are other issues that attract their attention, and some of it is that they believe shamelessly propagated lies.

But some of it, as for so many Americans, is misunderstanding how health care costs work. Most of the money is not spent on most of the people. Journalists, living in their middle-class, young-to-middle aged worlds, are among the worst perpetrators of misunderstanding healthcare usage, writing about their rotator cuff surgery or their neighbor’s strep throat. 50% of people account for only 3% of health care costs; thus half of us are essentially “rounding error”. 5% of people account for 50% of costs. The other 45% are using about “their share”, or 47% of health dollars. If we look at this graphically, using (for fun) red,blue, and purple, we see:

The 45% of people who are using about “their share” are those who have chronic health problems and have to go to doctors more frequently, and get more tests, but don’t have frequent hospitalizations. It also includes the folks who have, in a given year, surgery or physical therapy – like for those rotator cuffs – but usually are in the low use group. This portion of the population includes a disproportionate % of seniors, who have more chronic disease and use more health care services.

Another way to look at it would be for $100 spent on 100 people (whose costs are distributed as per the whole population), 45 people would cost about “their share”, just over $1 each, 50 people would cost $0.06 (6 cents) each, and 5 people would cost $10 each.

Seniors, because they are also more likely to have multiple chronic health problems that require multiple hospitalizations, and because they are more likely to have cancer, which costs a lot to treat, are also disproportionately represented in the high cost group. However, they are still the minority of that group. These high-cost users are the “outliers”, and also include other people with cancer, people with trauma, as from auto accidents, requiring multiple surgeries, and premature and sick babies requiring incredibly expensive care in neonatal intensive care units.

This is an extremely important concept, because it is the reason that insurance exchanges have gone bankrupt in every state that has tried it, and will not work at the federal level. While it is acknowledged that insurance companies “game the system” and “cherry pick” healthier people, the efforts in the current legislation to try to prevent that will not be sufficient, because, given the above data, they don’t have to enroll only people in the “low cost” group (although I’m sure they’d like that!), they just have to find subtle ways to get rid of one or two of those 5 high-cost people. For each one of those people they can avoid, they save the same amount as their cost for 10 “mid-user” people or 167 “low users”. None of the current legislation will be rigorous enough to force each insurance company to enroll 5% of the high users (in part because we don’t always know who they’re going to be – see below – which is also why they can’t have none of them). The insurance “exchanges” for uninsurables will then, soon, just as they have in each state that has tried it, become unsustainably expensive while the insurance companies continue to make big profits. See the amazing report in the Washington Times “Insurer ends health program rather than pay out big” to get a sense of what we can expect from insurance companies. (And note that this is from a very conservative newspaper!)

So if everyone looks at it from the point of view of their current self-interest, those in that “low use, low cost” group wouldn’t want to pay more for all those high-cost, high-use folks. This year, today, it wouldn’t be in our self-interest. Except…

…we don’t know when we, or our teenage children, will be in a car accident that rockets them from the low-cost to the high-cost group. And we don’t know when we’ll have a premature baby, or be diagnosed with cancer, or have us or our parents move from the mid-cost, have-chronic-conditions-and-see-the-doctor-but-rarely-be-hospitalized group to the high-cost be-hospitalized-a-lot-including-in-intensive-care group.

So we are all in it together. And the only system that prevents “gaming”, “cherry picking” and adverse selection is having one system. And that is what we need to adopt.

With profound thanks to Robert Ferrer, MD, MPH

[1] In 2006, the Kansas 2nd Congressional district that includes SE KS, but also the city of Topeka, elected a Democratic Congresswoman, Nancy Boyda, to replace reactionary Jim Ryun, remembered mostly as a KU mile champion. But in 2008, she was defeated by a Republican. SE Kansas also has a populist history, with Crawford County being one of 3 counties in the nation to vote for Gene Debs in 1920.

Saturday, October 17, 2009

.NPR recently covered a story about the response of Jewish settlers on the West Bank to the Israeli army tearing down illegal “outpost” settlements, in response to court order (“Evicted Israeli settlers attack Palestinian land”). The settlers are, apparently, responding by burning down the olive groves and other property, belonging to nearby Palestinian farmers.

Let’s get this straight: Jewish settlers, in Palestinian territory, establish illegal “satellite” settlements in an absolutely purposeful aggressive gesture against their own government, the Palestinian people, and the rest of the world. Israeli courts declare them illegal, and send in Israeli security forces to tear them down. In response, the settlers destroy the property of nearby Palestinians. This they call the “price tag”.

So I waited, as they interviewed the Arab farmer whose groves were burned, the attorney who had brought the issue to the court, and a settler who asserted their right to act because the “Jews have a right to all this territory”. I waited to hear how the settlers who committed this atrocity, identified after an intensive police investigation, had been jailed and were awaiting trial.

Didn’t hear it. Did hear that the courts are now more reluctant to issue such orders. So they are not arresting and prosecuting the thugs who perpetrate these acts, but rather awarding them victory. This is not ok.

I was going to say that the settlers who destroyed the lands of their Arab neighbors were nothing more than common criminals, to be arrested, prosecuted, and imprisoned. But they are more than common criminals. They are hate criminals. I do not know Israeli law, but in the US these would be clearly hate crimes, and treated much more harshly than common crimes.

The settlers, as a movement, are wrong, but this sort of tactic is execrable. These are bad people because they are doing bad things, very bad things, and the failure of the Israeli government to immediately, enthusiastically, and harshly punish this behavior is intolerable. These people, these bad people, give the Jewish people a bad name.

Jews, as a people, probably because of their own history of oppression, have always been in the forefront of progressive social movements. They are and have been very active in movements for social justice, including the civil rights movement in the United States, including the war against fascism (by some estimates 80% of US volunteers who fought with the Lincoln Battalion in Spain were Jewish). In South Africa, a very high proportion of the white participants in and leaders of the anti-apartheid movement were Jewish. Across the US and the world, where there are any Jews, they are disproportionately represented in fights for human rights. Even in Israel; while even progressive Jews in the US are reluctant to criticize Israel, in that country there are many who stand for human rights.

The perpetrators of these acts, and their supporters, are acting to reverse the Jewish people’s tradition of empathy and support for the oppressed, becoming oppressors themselves. Just as most Muslim people do not wish to be defined by Al Qaeda, these criminals cannot be permitted to define what it means to be Jewish. They are the Jewish Taliban, and deserve no support or sympathy.

Wednesday, October 14, 2009

.The Wall St. Journal, October 13, 2009, contains a “Review and Outlook” piece (editorial) titled “The War on Specialists”. The opinion piece decries the way that “ObamaCare” is going to try to save money by reallocating funds from subspecialists to primary care doctors. As an example, they talk about the proposed cuts to some of the “basic tools of heart specialists”, echocardiograms and cardiac catheterizations. They quote American College of Cardiology CEO Jack Lewin, MD, as saying that it will cause a “horrible disruption” that may make senior patients wait days for tests and services, because staff will have to be laid off. (Of course, it could lead to SHORTER waits if the cardiologists do more procedures per day to try to make up that income!) The WSJ correctly points out that the cuts don’t necessarily cut any spending; “…the RVUs merely redistribute it from one medical bucket to another.” That is, the cap on spending on medical care (called the Sustainable Growth Rate, or SGR, which I have previously addressed) would increase primary care doctors’ reimbursements while it cuts those of subspecialists.

But would these predicted disasters actually come to pass? Hard to know; but what we do know is that the reimbursement for subspecialists is many times that of primary care physicians, so much so that it is more and more difficult to convince medical students, graduating with large debt, to enter primary care. The assertions of the WSJ, and Dr. Lewin (who used to be director of Public Health for the state of Hawai’i, and an advocate for the public’s health, before taking this more highly-paid job) are simply assertions. Following the same pattern as the paper I discussed recently by Dr. Cooper (“’Uncomplicated’ Primary Care?”), and others, they ignore data that shows that there needs to be a balance between primary care and subspecialty care in order to achieve the best outcomes in the public’s health, and that the current ratio is way out of balance. I have cited, over and over again, the literature, from many places and many times, that demonstrates this. And is conveniently ignored in this piece, attacking this consistent data as “based on a flimsy survey” that HHS has done and that Secretary Sebelius and budget director Orszag will not discuss with poor Dr. Lewin. Why bother to look at the data when you can simply assert your beliefs?

The WSJ article ignores the fact that much of the care provided by, for example, cardiologists, is excessive; that supply generates demand. The work of the researchers at the Dartmouth Health Atlas show the dramatic differences in costs of care and frequency of expensive procedures by region – often based on the density of subspecialists – without appreciable differences in health outcomes. (Or, when there are differences, that the outcomes are better where there is less use of expensive technology!) It makes the key mistake of conflating “health” with “preventing death”. Of course, we all want to prevent our deaths when we see meaningful life ahead, but the extraordinary expenditures that often prevent death only by weeks, days or hours, would often be better spent on having a sufficient number of primary care doctors to be able to maintain health, control chronic disease, and do preventive care. [1]

“Markets,” the WSJ asserts, “are supposed to determine the composition of the workforce, not a command medical economy run out of Washington.” Perhaps, but the situation that exists today is far from a “free market”. In addition to the almost-unique ability of medical specialists to generate demand based on supply, as discussed above, the simple fact is that it is the “command economy”, not the market, that accounts for the current, inequitable state of reimbursement. The assignment of RVU values grossly overvalues procedures in comparison to time spent with the patient discussing their health, managing medical problems and planning treatment. It is the fact that Medicare (and thus other insurers, whose reimbursements are almost always tied to multiples of Medicare rates) and its current method of reimbursing fee-for-service by RVU values that have created this inequity. What is needed is to correct it, and this cause is not served by blatantly false assertions that it is a free market, rather than a stacked system, that has created the problem.

While Jack Lewin has become an embarrassment to public health, he is doing his job. The WSJ can advocate for “markets” but should not imply that the status quo is a result of the operation of free markets, rather than a reflection of the way the deck is currently stacked. The WSJ provides no service whatever when it tries to make a discussion about what best serves the health needs of the American people a partisan cause. It can disagree with me on the issues, it can even choose to trumpet its disregard for facts, but this is not, and should not be a Democratic / Republican issue. The health of our people is too important.

[1] For example, the most common outpatient medical visit, code 99213, taking about 20-30 minutes, in which I can address multiple chronic health problems as well as preventive services, is valued at 0.92 work RVUs. If I then clean the wax out of the person’s ear, I get another 0.61.

Monday, October 12, 2009

.Kansas City has the largest World War I memorial in the nation, Liberty Memorial, associated with the incredibly impressive National World War I Museum. It is a must-see for a visitor to Kansas City, and even worth a special trip. It is impossible to tour the museum and not be impressed by the enormity of this almost-forgotten war, the enormity of death and destruction, the virtual wiping out of an entire generation of young men in Europe, and the wanton disregard for people that led to an entirely unnecessary war being fought. The trenches must have been unbelievably awful; the image of men firing at each other across a no-man’s land difficult to envision.

WWI brought in its wake many writings that should be remembered and re-read, including the remarkable All Quiet on the Western Front by Erich Maria Remarque, and the heart-rending poems of the “World War I poets”, many of whom lost their lives, such as Rupert Brooke, Wilfred Owen, John McCrae, Isaac Rosenberg and others. One cannot read these works without tears and regret and wondering what it was that led to, in England alone, the loss to death or wounds of 8% of its population. If you prefer your tears to musical accompaniment, I recommend “Battlefields of Green”[1] by Scottish-Canadian singer John McDermott; while it includes lovely renditions of standards such as “Danny Boy”, most of the songs are about WWI, including a powerful performance of Australian Eric Bogle’s anti-anthem, “And the Band Played Waltzing Matilda”.

World War I was not fought because Gavrilo Princip assassinated the Archduke Ferdinand of Austria, although that may have been a spark. What was it that led these countries of Europe, many of them (such as England and Germany) ruled by cousins, to enter this horrific conflagration? At its base it was a mercantile war, about whose merchants and manufacturers would control markets and be able to make money (and, of course, the war munitions makers, who did extremely well). For their economic self-interest, for the greater wealth of a small number of plutocrats, millions of young men were killed and wounded, Europe was decimated, and the seeds of WW II were sown. But boy, did those plutocrats do well! Not only did those in Europe do well, so did those in the US, which entered the war late, had (relatively) fewer casualties, and had no battles on its territory. The literature of this time is “The Great Gatsby”, the profligate 1920s, ending in the crash of ’29, the Great Depression, and the rise of Nazism and Fascism in Europe. (required reading is Howard Zinn's classic "People's History of the United States", Ch. 14, "War is the Health of the State". Interesting to note this in a "health" blog.)

Why talk about WWI now, here, in this blog? I suppose that I could tie it to the pointless wars in Iraq and Afghanistan that continue to claim lives, and there would be validity to that, although now our wars are fought in other people’s countries, in the third world, and not by all of our children but predominantly working class children. However, I am more struck by the parallels to today in that policy continues to be made, and young lives sacrificed in the cause of increasing the “abundance of those who have much”. Not a year since the “crash” of 2008, our bankers and financiers are back to the same practices of excess in their personal lives and excessive risk-taking in their public actions that put the entire world economy into a recession and continues to cause amazing pain to millions. We are told that the economy is improving, which means that the bankers and financiers are doing well. We are told that the number of new job losses is less this month than last. Not that jobs are being created, understand, but that the rate of loss is less. There are 6 people for every available job. This is not improvement. This is bad. It is bad for the real people who live in this country. It is intolerable. We did not think that the Bush administration cared for regular people, but had hoped that the Obama administration did. No such luck. The predators are feasting over the spoils of the economy and the regular people still suffer.

People are angry. They are angry because they do not have jobs, because more jobs are being eliminated than created, because they do not see the government doing anything for them. On the heels of the Great Depression, FDR instituted the New Deal, including Social Security, banking reform, and a massive jobs program. On the heels of the current depression we bailed out the banks. Something is wrong with this picture.

In the 1930s, anger led to massive movements on the left and on the right. The right is always funded by the wealthy and led by ideologues, but requires regular people for a mass movement. These people are convinced that, somehow, their interests will be met by policies that are entirely directed at benefiting the wealthiest and the corporations they own; racism, jingoism, and mainly lying are popular and effective methods. The young Englishmen who died in WWI for the profits of the mercantile sector were sent to die for “King and country".

It is not only in war, and in the economy, that our government is doing the bidding of the super-rich and corporations and ignoring the people; it is happening on every front. Michael Moss, in the New York Times, on October 4, 2009, reported on the poisoning of our ground beef supply with pathogenic E. coli bacteria, E. Coli Path Shows Flaws in Beef Inspection, because of inadequate testing by the slaughterhouses, grinders and processers, and government. The story of the effects on people were horrifying, but more horrifying is the quotation from “Dr. Kenneth Petersen, an assistant administrator with the department’s Food Safety and Inspection Service” who “said that the department could mandate testing, but that it needed to consider the impact on companies as well as consumers. ‘I have to look at the entire industry, not just what is best for public health,’ Dr. Petersen said.” This does not help us to gain faith in our government and feel that, in Lincoln’s words, it is acting “of the people, by the people, and for the people.”

World War I was an unmitigated disaster, fought for terrible reasons and leading to tremendous devastation. Well, maybe a little mitigated. A lot of arms manufacturers made a lot of money, and the corporations from the victorious companies gained markets. But it was, and is, inexcusable; and as inexcusable are the ways we continue to attract young men to die for markets, as they did in WWI. Wilfred Owen’s poem “Disabled”,

…One time he liked a blood- smear down his leg,After the matches, carried shoulder-high.It was after football, when he'd drunk a peg,He thought he'd better join. - He wonders why.Someone had said he'd look a god in kilts, That's why; and maybe, too, to please his Meg,Aye, that was it, to please the giddy jiltsHe asked to join. He didn't have to beg;Smiling they wrote his lie: aged nineteen years.

Germans he scarcely thought of; all their guilt,And Austria's, did not move him. And no fearsOf Fear came yet. He thought of jewelled hiltsFor daggers in plaid socks; of smart salutes;And care of arms; and leave; and pay arrears;Esprit de corps; and hints for young recruits. And soon, he was drafted out with drums and cheers.

Some cheered him home, but not as crowds cheer Goal.Only a solemn man who brought him fruitsThanked him; and then enquired about his soul.

Now, he will spend a few sick years in institutes, And do what things the rules consider wise,And take whatever pity they may dole….

characterizes too many veterans today.

Yes, something is wrong. We need more than wars to send our young people to. We need jobs for them to do. And since the corporations we bail out won’t create them, we need the government to do it; a massive works program to rebuild our infrastructure for all of us. We need health care for all of us. We need a government that works for all of us. I hope, and I worry, and I fear that even under this President it will not.

Thursday, October 8, 2009

.I have often written about the importance of primary care, the shortage of primary care physicians, and the fact that fewer medical students are choosing primary care careers, which will exacerbate the problem. A key part of this analysis is the large number of studies, by researchers from a variety of settings, that show that the presence of a higher proportion of primary care doctors decreases cost and increases quality.[1],[2],[3],[4],[5] Indeed, there are studies that show that health disparities in infant mortality and low birthweight can be virtually eliminated by a greater presence of primary care.[6]

However, not everybody agrees. In an earlier post, More Primary Care Doctors or Just More Doctors?, I discussed the position taken by Dr. Richard Cooper, former Executive Vice President and Dean of the Medical College of Wisconsin and currently Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, who argues against this position, as well as rebuttals from some of those he has criticized. In a recent publication supported by the Physician’s Foundation, a group comprised primarily of state and local medical societies, “Physicians and their practices under health care reform: a report to the president and the congress”, Dr. Cooper and a group of equally distinguished colleagues restate this position; in particular that the value of primary care is overstated. In an excerpt from the Executive Summary they note:

"Primary care has been a central focus of health care reform. In modeling the future workforce, the Project Team acknowledged the critical importance of primary care services and the role of generalist physicians in providing them. However, the Team rejected the claim by Starfield and others of lower mortality in regions with more family practitioners as a statistical anomaly, and it questioned the wisdom of deploying generalist physicians to take responsibility for the proposed medical homes. Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care"

This is quite a strong statement in opposition to what I, and many others, have been saying in support of the importance of primary care to the health of the public, so of course one looks for the supporting data, especially for the striking dismissal of the work of Starfield and others as “a statistical anomaly”; however the data isn’t there. Presumably, when people are so distinguished and feel their positions so strongly, such data is unnecessary. One distinguished colleague put forward this definition:

Statistical anomaly: A consistent finding, in multiple nations and health systems that disagrees with my current self-interest and bias.

That says it very well. If you have no data to justify publication in peer-reviewed journals, you can continue to perpetrate your ideas in foundation-sponsored opinion pieces.

Several organizations, including the American Academy of Family Physicians (AAFP) and the Association of Departments of Family Medicine (ADFM) have protested this publication to the sponsors, the Physicians Foundation. The Foundation took the position that it commissioned the study but did not endorse it; that it was supportive of primary care, and chose to focus on other findings of the report (such as that socioeconomic differences make a difference in geographic variation, which the Dartmouth Atlas researchers are purported to have ignored in their analysis). The PF states its unequivocal support of primary care in a letter to the President of ADFM: “As for the Physicians Foundation (PF), it would never do anything to damage primary care.” Nonetheless, the AAFP found this inadequate; its formal response to the PF includes the following:

“This report is an attack on decades of sophisticated research that validly supports the value and need for improving access to robust primary care using a thin vein of research that has been publicly demonstrated to be oversimplified and wrong. The authors’ perspectives and opinions are welcome in the debate about how to reform the health system and physician workforce, but this report is largely opinion richly dressed in discredited, unsophisticated research.

This study is largely a recapitulation of the primary author’s paper in Health Affairs in January of this year[7]. In that same issue, several researchers pointed out the fundamental flaws in this simplistic research showing that important basic adjustments showed this work to strongly support the prior studies it criticized. It continues to claim that population differences explain past findings for the value of primary care and variance in spending, when these were fully accounted for in these studies. This report does not repair those flaws. It labels several well-validated and valued studies as “anomalous” and “simple frameworks” without supporting evidence from other sources. We feel that such claims carry an obligation to point out specific errors of methodology or data, not just recapitulation of personal belief. The burden of proof is still overwhelmingly against the evidence upon which this reports rests. Its foundation is flimsy.”

Enough said about the lack of intellectual rigor, and essentially incorrectness about this piece. More important, I believe, the other assertion in the quote from Cooper’s paper, above, neatly packaged in the sentence “Indeed, faced with deep and prolonged physician shortages, it saw no need for physicians to expend effort on uncomplicated primary care". What is this “uncomplicated primary care” of which you speak? The idea that provision of primary care is simple, unchallenging intellectually, not worthy of the training of a physician, and could be done by someone with much less training, is a position put forward by other specialists and subspecialists that is:

· Common, especially in speaking to medical students,· Derogatory, and offensive,· Self-serving, since obviously the services provided by the subspecialists are much more rigorous and difficult, and· Wrong.

The myth is that primary care is about patients with colds and high blood pressure checks. The reality is that it is about people with multiple chronic diseases who need management of those conditions as well as coordination with whatever other specialists they are seeing; preventive services delivered; counseling and “asking for trouble” (“are you safe at home?”); discussion of whatever the other specialist may have recommended; and, of course, caring for acute complaints. This is hard, complex, time consuming and difficult. Yarnall, et. al, in the American Journal of Public Health, identified that it would take 7.4 hours a day for a primary care physician to just provide the preventive services, not to mention all the other services above, especially chronic disease management.[8] One of my residents recently returned from a rotation on cardiology; on her first day she was sent to see a patient and returned in 7 minutes. “That was fast,” said the cardiologist. “You just wanted me to address their heart problem,” the resident, used to caring for many different problems in a family medicine visit, replied. Perhaps this is cognitive dissonance for the subspecialist (or “partialist”), who has to believe that their in-depth knowledge of one particular set of conditions is at a higher level than managing the whole person with all of their complex medical, psychological, and social and economic issues.

Another wise colleague, who believes that “The question of what is intellectually challenging and worthy of training and intellect is a classic example of hubris perpetuated by subspecialists and academic health centers,” asks the following question of his medical students:

Taking care of a 55 yo with diabetes, hyperlipidemia, hypertension, coronary artery disease, chronic renal insufficiency, who is depressed, has a rash, erectile dysfunction, esophageal reflux and who is taking care of his elder mother with Alzheimer's dementia.”

I just had the opportunity to review the charts of the patients seen by one of my first-year family medicine residents in one clinic session recently. They included:

Sunday, October 4, 2009

.Old age, at whatever chronologic age it happens to one, is not an easy time. The body loses its resilience, often strength, and resistance to disease. Seniors account for the bulk of medical spending because chronic disease is so much more common. It is a time of vulnerability, both physical and socioeconomic; most seniors are living on fixed incomes and, after children, they are the demographic group most likely to be living in poverty. So it is quite understandable that many seniors would be worried about threats to the few things that they feel that they can count on to support their lives, especially Medicare and Social Security. It is also understandable, and completely unconscionable, that reactionary politicians and blowhards in the media would play upon those fears for their own political ends, which are usually about supporting the greater amassment of wealth for the already rich and powerful.

We already know about “death panels”. Hopefully, most people know, by now, that they do not exist, they never existed, and nobody was proposing that they exist. It was a falsehood made up of whole cloth, an insidious perversion of the idea that our government (which supports most of the research as well as much of the care already) support research into what medical interventions work and what don’t, and assess the cost:benefit ratio for those procedures. All of us, seniors and non-seniors alike, want to have what will benefit us, and do not want, particularly when we are most vulnerable, interventions that will not help and only cause discomfort, false hope, and cost us money besides.

I, along with many others, have made fun of the comment, unfortunately often heard, “Keep the government’s hands off my Medicare!” This seems like a joke – doesn’t everyone know that Medicare is a government program? But I guess not. Medicare, in 1965, and Social Security, in the 1930s, were progressive programs that have become the most valued and hallowed institutions in our society. They help to ease the pain and insecurity of old age. And – and let me be absolutely clear on this – they were completely opposed, in the 1930s and 1960s, by the political ancestors of those who are opposing government health reform now.

Let me say this again. The McConnells, McCains, Grassleys, Boehners, and Cantors, the Limbaughs, O’Reillys, Becks, and Hannitys, the AMA and the AHA and manufacturers’ associations of those periods, absolutely opposed the government intervention that created Social Security and Medicare. Their ideological heirs today are charlatans, liars and cheats to pretend that they are defending it now.

The latest scare tactic is to imply that those receiving Medicare would have their coverage watered down because all these other people would now be covered. To even imply this is an immoral and egregious crime. The best system, as I have often advocated, is Medicare for All. The additional money it would cost would not be equivalent to multiplying the percent now receiving Medicare by everyone else, because those receiving Medicare, the aged, blind and disabled, are the population already requiring the most care. The savings, not simply on insurance company profits but on the huge administrative infrastructure both insurers and providers have to protect those profits, would be enormous. Even in the tepid, inadequate reforms being proposed by the Senate Finance Committee, the additional funds appropriated would address this need. Medicare recipients would not lose quality care; savings being proposed are those that would come from no longer paying for worthless but expensive procedures, and from eliminating Medicare fraud.[1]

Nonetheless, unsigned and unattributed inflammatory emails continue to arise unsolicited, as this one recently forwarded by a friend:

Subject: Info For Seniors

Congress vote themselves cost of living adjustments (hefty ones at that)....what's wrong with this picture?

For the first time in history, Congress will not allow an increase inthe social security COLA (cost of living adjustment). In fact, theHenry J. Kaiser Family Foundation predicts there may not be any COLAfor the next three years. However, the per person monthly Medicareinsurance premium will be increased from the 2009 premium of $96.40 to$104.20 in 2010 and to $ 120.20 for the year 2011.

Let's send this to all seniors that you know. Remind them not to votefor the incumbent senators and congressmen in the 2010 and the 2012elections.

The reason there will be no cost of living adjustment (COLA) for 2 (not 3) years is that the Consumer Price Index (CPI), to which it is tied, went down. Remember the recession? Part B Medicare payments (this is what pays doctors, and is paid by individuals, not the Medicare trust fund; the latter, to which we contribute from every paycheck, funds only Part A, hospital costs) will still go up, because medical costs rose despite the recession.

75% of Medicare recipients will not see an increase in their Part B payments because the law contains a "hold harmless" provision that prevents the total from decreasing from one year to the next. That is, it prevents the increase in payment for Part B from exceeding the increase in income from Social Security. Of the other 25% of Medicare recipients, 17% are "dual-eligibles" who also get Medicaid because they are poor; their Part B premiums go up, but Medicaid already pays them and will continue to do so. 3% are folks who just retired this year and thus aren’t covered by the “hold harmless” provision because they payments can’t "go down" (they are receiving SS for the first time). The last 5% are higher income seniors -- those with a modified adjusted growth income of $85,000 for individuals and $170,000 for couples who are (absolutely correctly in my opinion) presumed to be able to pick up the few extra dollars a month. (Part D, the drug program, is not covered by the Hold Harmless Provision, so its premiums will go up.)[2]

Another target has been cuts to the Medicare Advantage (formerly Medicare-Plus-Choice) program (which is Medicare Part C.) I have criticized this program as one more give-away to the insurance companies in a previous blog. To understand the issue here, you need to understand the difference between fee-for-service and capitation (as in HMOs). In fee-for-service care, which is what most insured people, as well as most Medicare recipients have, providers (doctors, hospitals, equipment providers) are paid per-service or per-item. In an HMO, the provider (the HMO) receives money in advance and then provides all covered care to the beneficiary. Medicare Advantage plans have the same plusses and minuses as other HMOs – which is to say that they vary tremendously by HMO. Most provide (relatively low cost, but valued) “extra” services, such as glasses and hearing aids. They may or may not provide the actual services that one needs when one is sick. Remember – they already have the money, and anything they spend on you is loss of profit (the “medical loss ratio”). Unsurprisingly, the HMOs (and Medicare Advantage) programs that are owned by for-profit insurance companies are usually meaner (in the sense of “cheaper” and well as the more common definition) than are the few remaining “consumer cooperatives” such as Group Health of Puget Sound and HIP in NYC, or Kaiser Permanente (somewhat different in that it was initially founded by a corporation for its employees). Some recipients of Medicare Advantage are angry that it may be cut back, but the fact is that most of these programs restrict access to care more than traditional Medicare. Both of these points of view are expressed in letters to the editor of the New York Times, Sept 30, 2009; I commend especially the data-driven, rather than solely opinion, letters of Barbara Kennelly and Samuel Brooks.

These letters are in response to a New York Times editorial (“Medicare Scare Mongering”, Sept 27, 2009), which, among other things, calls for changes in this program. Acknowledging the extra benefits that Medicare Advantage offers, it correctly points out that it is unfair and unreasonable for Medicare to pay more to these insurers than it pays for other recipients. Some Medicare recipients pay additional money out of their own pockets to be covered by an HMO; this is their choice and if it is a good HMO, may well be a wise decision. But it is wrong for Medicare to subsidize, as it has, the insurance company providers by paying more for Medicare Part C (most of which goes to profit, not patient care, or, excuse me, “medical loss”!), and the Times is correct to call for such change.

The original Social Security, as we all know, was championed and pushed through by President Franklin D. Roosevelt -- against the opposition of conservatives who called him a “socialist”. All seniors, and all of the rest of us who will hopefully become seniors, owe him thanks. The following words are carved on his memorial:

“THE TEST OF OUR PROGRESS IS NOT WHETHER WE ADD MORE TO THE ABUNDANCE OF THOSE WHO HAVE MUCH; IT IS WHETHER WE PROVIDE ENOUGH TO THOSE WHO HAVE TOO LITTLE".

We need to keep these words in mind, live by them and make policy by them. We must resolutely oppose those in Congress or the private sector whose goal is to “add more to the abundance of those who have much”, often because those who have much share some of it with them, especially when they deviously seek to achieve their ends through vicious scare tactics. They are immoral and wrong.

[1] As I have indicated, I believe that the government way overstates Medicare “fraud”. The regulations are complex and ever-changing, and the vast majority of this is not fraud at all, but simple mistakes. One can liken this to the IRS. But I am certain that there is some true Medicare fraud, just as there is income tax fraud.[2] Also note that it is fine to call for voting out those in Congress, but, but the ones who voted this in are largely dead, as the linking of SS and Medicare to the CPI was done in 1973.